ASHA workers conduct a door-to-door survey for COVID-19, New Delhi, June 26, 2020. Photo: Reuters/Anushree Fadnavis
- A new guideline, the first of its kind, by the Union health ministry to have a public health management cadre is a welcome move for India.
- The health management cadre is expected to improve the overall management of national health programmes and public healthcare facilities.
- The guideline specifies an MBBS degree to be a prerequisite for becoming a public health specialist. This is however both contradictory and impractical.
- The second way in which the guideline is short-sighted is that it fails to acknowledge the work of existing public health workforce personnel at the grassroots.
A recent initiative by a few states to implement the ‘right to health’ and a new guideline by the Union health ministry to have a public health management cadre are together welcome moves for a country that has been offering MPH degrees outside medical schools for more than two decades.
The national guideline in particular is the first of its kind.
It describes the core task of public health systems to include estimation of disease burden and an assessment of needs, based on which the government can deliver preventive, promotive, curative, rehabilitative and palliative health services. It also talks about a public health cadre, a specialist clinical cadre, a health management cadre and a teaching cadre.
The health management cadre is expected to improve the overall management of national health programmes and facilities that provide primary, secondary and tertiary care in the public sector.
This said, the guideline document is short-sighted on two counts.
First, it specifies an MBBS degree to be a prerequisite for becoming a public health specialist. This is however both contradictory and impractical. The guideline itself mandates those with MBBS degrees to acquire a postgraduate degree in public health to become eligible for recruitment in public health departments. This in itself is an open acknowledgement of the limits of the individual-oriented clinical training to address public health challenges at a population level.
Further, a major human resource challenge of Indian health services is to ensure qualified MBBS graduates work in rural and underserved areas. MBBS professionals with a postgraduate degree in public health can’t be any different.
The second limitation is the document’s silence about frontline health workers, who are currently engaged in public health work by default. They include (i) ASHA workers, (ii) auxiliary nurse midwives (originally responsible for maternal and child health programmes outreach), and (iii) multipurpose workers (who have historically played an important role in disease control programmes and are integral to the public health system).
There is a need to revive the personnel of these work groups at the grassroots level if we are to achieve effective public health policy, planning and management at the higher levels.
Two traditions
The discipline of public health has at least two different traditions. The first is of the techno-managerial kind, with its origins in the early 20th century and mostly identified as a sub-discipline of medicine.
It was famously propagated by the Rockefeller Foundation in the West, and based on which the Johns Hopkins School of Public Health and the London School of Hygiene and Tropical Medicine were established. This field was originally known as ‘preventive medicine’ in the US and as ‘public health’ in the UK and other European countries.
The Indian counterpart of these institutions is the All India Institute of Hygiene and Public Health, Kolkata. Established in 1932, it is the oldest public health institution in the Southeast Asia region.
An alternative tradition, developed in the Latin American context and known as social medicine, focused instead on changing the social context of people and their lives as a way to achieve better population health. This approach became popular and gained acceptance across the world as a more effective, successful and sustainable approach in public health – one that considers the societal context and the lives of people central to every public health intervention.
The acknowledgement of the social determinants of health as the key principle that guides public health practice in contemporary times is testimony to this tradition. Epidemiology – one of the basic sciences of public health practice – has also moved from an individualistic-biologic determinism to that of a population-oriented societal context. It is known in its latter form as social epidemiology.
Public health education across the world has also transformed itself into independent schools of public health, isolated from medical schools. This is why India established public health education institutions across universities in the country based on an expert committee’s recommendations in 1996.
But in spite of them, the biomedical approach to public health has always implicitly dominated, in India and other countries. Two possible reasons for this could be the dominance of medical professionals in health policy and planning decisions in these countries and the power that the practice of medicine wields in public health matters.
This state of affairs has a price, of course: the potential of public health disciplines to offer solutions for various public health problems is limited to only those within the biological sciences, owing to the underlying philosophy of biological determinism.
Frontline health workers as public health workers
The second way in which the guideline is short-sighted has to do with the delivery of health services. Specifically, the guideline fails to acknowledge the work of existing public health workforce personnel at the grassroots level.
We need more clarity on the roles and responsibilities of different public health cadres across different levels of the public health system. Institutions of public health practice need to be imagined as being distinct from institutions of medical practice – but also need to integrate with existing health services at the local, state and national levels.
Such integration is desirable because effective public health practice calls for regular community outreach, which can generate reliable data necessary to reduce our disease burden. At present, these tasks are carried out by frontline health workers in a haphazard manner, with duplication of activities and poor accountability.
First, frontline health workers in the health services evolved historically as a response to the needs of disease control programmes and were never provided a comprehensive public health purpose. Second, and more importantly, they are supervised with a more programmatic purpose and not by public health institutions.
For example, the government deployed ASHA workers to increase the number of women who gave birth at healthcare institutions; the workers were trained specifically for this. But today, they are roped into every health department activity, ranging from distribution of medicines to reaching malaria and tuberculosis patients, even for contact-tracing and follow-ups during India’s COVID-19 epidemic.
So discussions on India’s public health cadres should include the possibility of empowering existing frontline health workers to be public health workers at the community level. The challenge here will be that each of these workers was added at different points of time in history, with diverse interests, competencies and skills – even though all of them are working to improve public health.
The public health management cadre that the new guideline proposes can only be effective if these public health workers can be the pillar holding up India’s public health institutions. This is because the core task of public health is to ensure regular community outreach to identify and resolve health problems, and to regularly collect and analyse health data for effective public-health planning.
Mathew George is professor, Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai. The views expressed here are personal.